<?php echo $header; ?>
<div class="container">
	<div class="texto_web">
		<h1>
			<?php echo $title;?>
		</h1>
		<p>
			<?php echo $message ?>
		</p>
	</div>
	<?php echo $content_top; ?>
	<?php echo $content_bottom; ?>
	<div class="denuncia_form">
		<form role="form" class="clearfix" method="post"
			action="index.php?route=phone/number/process"
			onsubmit="return controlaEnvio();">
			<div class="texto-web">
				<h3>
					<?php echo $text_report_number;?>
				</h3>
			</div>
			<fieldset class="report-number">
				<div class="form-group">
					<label for="numero"><?php echo $text_phone_number;?> <!--i class="fa fa-asterisk"></i-->
					</label> <input type="text" name="number" class="form-control"
						id="numero" placeholder="<?php echo $text_note_phone_number;?>"
						value="<?php echo $number; ?>"> <span class="error"
						style="color: red;"><?php echo $error_number; ?> </span>
				</div>
				<div class="form-group">
					<label for="comentario"><strong><?php echo $text_comment;?> </strong>
						<!--i class="fa fa-asterisk"></i--> </label>
					<textarea id="comentario" name="comment" class="form-control"
						rows="5" placeholder="<?php echo $text_note_comment;?>"><?php echo $comment; ?></textarea>
				</div>
				<div class="form-group">
					<div class="captcha"
						style="margin: 0px; margin-bottom: 10px; height: 115px">
						<img style="margin-bottom: 10px" id="captcha"
							src="<?php echo $captcha_link;?>" alt="" /> <input type="text"
							id="captcha_input" name="captcha"
							class="captcha_code bold center"
							placeholder="<?php echo $text_note_captcha;?>" maxlength="6"
							value="<?php echo $captcha; ?>" />
						<?php if ($error_captcha) { ?>
						<span class="error" style="color: red;"><?php echo $error_captcha; ?>
						</span>
						<?php } ?>
					</div>
				</div>
			</fieldset>
			<fieldset class="right collapse1">
				<div class="form-group">
					<label for="dueno"><?php echo $text_who_was_it;?> </label> <input
						type="text" id="owner" name="owner" class="form-control"
						value="<?php echo $owner; ?>" maxlength="45"
						placeholder="<?php echo $text_note_who_was_it;?>">
				</div>
				<div class="form-group">
					<label for="user"><?php echo $text_you_name;?> </label> <input
						type="text" id="user" name="user" class="form-control"
						value="<?php echo $user; ?>" maxlength="45"
						placeholder="<?php echo $text_note_you_name;?>">
				</div>
				<div class="form-group">
					<label for="tipo"><?php echo $text_call_type;?> </label><select
						id="call_type_id" name="call_type_id" class="form-control">
						<?php foreach($call_types as $calltype){ ?>
						<option value="<?php echo $calltype['call_type_id'];?>">
							<?php echo $calltype['name'];?>
						</option>
						<?php } ?>
					</select>
				</div>

			</fieldset>
			<fieldset class="captcha-button">
				<span class="nav-toggle"> <a><i class="fa fa-minus-square"></i><span>&nbsp;<?php echo $text_hide;?>
					</span> </a>
				</span>
				<div class="form-group" id="numeric_captcha" style="display: none;">
					<label for="tipo">Please resolve this operation: 10+7</label> <input
						type="text" id="please_fill" name="required">
				</div>
				<button type="submit" class="btn btn-default">
					<?php echo $button_send_report;?>
				</button>
			</fieldset>
		</form>
	</div>
	<div class="modal fade" id="errorModal" tabindex="-1" role="dialog"
		aria-labelledby="myModalLabel" aria-hidden="true">
		<div class="modal-dialog">
			<div class="modal-content">
				<div class="modal-header">
					<button type="button" class="close" data-dismiss="modal"
						aria-hidden="true">
						<i class="fa fa-times"></i>
					</button>
					<i class="fa fa-exclamation-triangle"></i>&nbsp;
					<h4 class="modal-title" id="myModalLabel"></h4>
				</div>
				<div class="modal-body" id="myModalMessage"></div>
				<div class="modal-footer">
					<button type="button" class="btn btn-default" data-dismiss="modal">
						<?php echo $button_close?>
					</button>
				</div>
			</div>
		</div>
	</div>
</div>
<?php echo $footer; ?>